Antidepressants During Pregnancy: What’s a Mom to Do?

I’m with you. None of us wants to have to take a medication while we’re pregnant. We’re trying to protect our babies from potential toxins. We go organic to avoid unnecessary chemicals in our foods, we switch to glass water bottles to avoid BPA, we stop drinking wine and coffee. So the last thing we want is to purposefully expose our babies to possibly unsafe medications!

But untreated depression in pregnancy can also be harmful – leading to a host of short and long term problems for mom and baby. This leaves pregnant mommas struggling with a really tough decision.

It’s a rock and a hard place kind of choice.

So what’s a pregnant mom to do?

Are Antidepressants Safe or Dangerous During Pregnancy?

Emerging data on many medications used in pregnancy, from tylenol to antidepressants suggests that we must continue to deeply question whether most are safe for use in pregnancy. All medications used for mental health cross the placenta, thus exposing the developing fetus to these drugs, and, in spite of widespread use, there’s still a lot we don’t know about their safety in pregnancy. Yet another recent study showed that paroxetine (Paxil), a widely used antidepressant in pregnancy, increases the risk of birth defects. While the risk is small, if this happens to your baby, that risk is 100% for you.

The most commonly recommended medications for depression (and anxiety) in pregnancy are the SSRIs and SNRIs, and these are really the only ones that are considered even remotely “safe.” Most other categories of antidepressants – mood stabilizers and tricyclic antidepressants, for example, are associated with congenital malformations and should almost always be avoided.

While substantial studies in hundreds of thousands of pregnant women do not show any harm from using these drugs while pregnant, other important studies, including by the National Birth Defects Prevention Study, have found that exposure during pregnancy increases the risks of complications including:

There is a controversial association with increased miscarriage risk. Additionally, newborns that had been exposed to maternal use of antidepressants during the pregnancy, may exhibit poor neonatal adaptation (neonatal behavior syndrome), which includes tremors, rapid breathing, and even persistent pulmonary hypertension.

Since 2004, drug-labeling laws require a warning about the potential for adverse effects on newborns to appear on antidepressant packaging.

Timing of use during the pregnancy (i.e., which trimester), and at what dose, may have an impact on safety, as does the choice of medication.

YES NO I feel more confident in the effectiveness or safety of medications than in natural therapies.

YES NO I understand that there is a risk to taking these drugs in pregnancy, including the risk of my baby having a heart defect, and I can accept that risk.

If you answered YES to any of the above statements, then an antidepressant might be the best choice for you at this time. If you answered no to all of these questions, are not having thoughts of self-harm, and have a solid support network, then it might be appropriate to try non-pharmacologic methods first.

I am sure that if you have decided you need to use an antidepressant, this was not easy. Trust that you are making the best choice at this time for you and your baby. To reduce the risks of antidepressant exposure for you and baby:

Choose a medication that is known to result in the lowest fetal/neonatal exposure whenever possible. Prozac (fluoxetine) is the best-studied medication with the highest safety profile, however, it has a tendency to accumulate in the breastfeeding baby, thus in spite of controversy over potentially being able to cause congenital defects (teratogenicity), Zoloft (sertraline) is typically the first line medication recommended during pregnancy.

Avoid the use of newly released antidepressant medications while pregnant – use only those that have been time-tested in pregnant women.

Use the lowest effective dose in the first trimester, increasing in the second and third trimesters, as needed to maintain symptom control.

If you are pregnant and wish to try to lower your dose, do so by tapering down by 10% each week to minimize the potential for relapse, remaining at the lowest possible dose at which your symptoms stay well controlled.

Add in non-supplement, non-pharmacologic treatments such as light therapy, yoga, and cognitive behavioral therapy, all of which have been found to be effective and do not interfere with your medication, but might allow you to effectively lower your dose.

What if I’m Already on a Medication?

If you got pregnant while already on an antidepressant, set up a time to discuss the risks of that medication on your pregnancy with your midwife or OB. Work with your care provider to switch you to the safest possible medication that will work for you, and at the appropriate dose.

If you are already on a medication that is preferred for safety in pregnancy, at a dose that is really doing the job for you, and you are past the first trimester, then sometimes the best thing may actually be to stay at that dose because sometimes lowering the dose just leads to rebound symptoms that are hard to control at a lower dose.

These really are tough decisions. While a non-pharmacologic approach whenever possible may be the ideal, keeping yourself in a healthy mental space is also essential for a healthy pregnancy and transition to motherhood feeling prepared and happy to meet and care for your new baby.

References

References

Benard, A. et al. The risk of major cardiac malformations associated with paroxetine use during the first trimester of pregnancy: A systematic review and meta-analysis. British Journal of Clinical Pharmacology.doi: 10.1111/bcp.12849.

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6 Comments

Thank you!! I am curious about breastfeeding? Do the same rules apply? I just had #3 5 months ago and am feeling VERY anxious and overwhelmed. I am left with the desicion of medicine or not.
Love your work!!!

So well needed!!!! This is a HUGE topic in my circle of friends. It is such a shame that it still remains a hush-hush topic in society. Going to share the crap out of it! —–side note when I got to push the FB share icon at bottom of post only half the box comes up so I cannot write in box and push share button……not sure if that is something on my end or yours. Anyways, thanks again you lovely lady!!!!!!!!!!!!!!

I was on an SSRI during pregnancy because I was too addicted and neither I nor my PCPs had the necessary info about weaning off of them (I had horrible withdrawal symptoms whenever I tried to titrate off using a regular schedule). I really recommend the book The Antidepressant Solution for women who want to get off of the drugs. He gives instructions about using a tailor-made schedule for titrating off. It worked for me.

I had hyperemesis for the entire pregnancy and I think that the SSRI was a serious contributor to that — ginger and pharmaceutical anti-emetics like zofran are both serotonin antagonists! My PCP put me on zofran for the HE, which was not a good idea because that put me into perpetual withdrawal from the SSRIs (although yes, it managed the vomiting), but neither I nor she realized what was going on at the time. Aviva — I wish I had had your pregnancy book and had been aware of other options!!!
I ended up being really depressed the whole pregnancy because of barely eating and Zofran-withdrawal from the SSRIs. I feel like all too often with pharmaceuticals it can become a game of wack a mole.
My sweet daughter is now almost two and has severe digestive problems. I suspect liver toxicity and there is certainly uncoordinated peristalsis and I think those are both because of the SSRIs as well (I am working really hard to help her with these with info from Aviva’s course and other places).
The other thing to know about SSRIs is that they are just barely more effective than placebos. Something to seriously think about before deciding to take them. I take that as good news: placebos can be really effective for depression!!